ML20055C316
| ML20055C316 | |
| Person / Time | |
|---|---|
| Site: | Millstone  |
| Issue date: | 02/21/1990 |
| From: | Conte R, Sisco C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML20055C315 | List: |
| References | |
| 50-245-89-19, IEB-88-007, IEB-88-7, NUDOCS 9003020079 | |
| Download: ML20055C316 (13) | |
See also: IR 05000245/1989019
Text
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REGION I
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Report No. 50-245/89-19
Docket'No.
50-245
License No. DPR-21
~ Licensee:
Northeast Nuclear Energy Company
P.O. Box 270
Hartford, Connecticut
Facility Name:
Millstone Unit 1
Inspection At:
Waterford, Connecticut
Inspection Conducted:
October 23 - 27, 1989
Team Members:
C. Sisco, Operations Examiner, Region I
A. Sutthoff, Human Fa:: tors Specialist, Office of Nuclear Reactor
Regulation (NRR)
G,Galletti,Huma9actorsSpecialist,NRR
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Team Leader:
Ob
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C. E. Sisco, Operations Examiner
'date
Division of Reactor Safety, Region I
Approved by:
M
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R. Conte, Chief, BWR Section
date
Division of Reactor Safety, Region I
Inspection Summary: This inspection was announced in order to review selected
deviations the licensee had taken from t.ne General Electric Topical Report
NE00-31331, Emergency Procedure Guidelines", Revision 4 and to determine that
Human Factor principles were utilized in the implementation of those guide-
lines. As a result of the inspection, the inspector also reviewed selected
comparisons of the E0Ps to the inspection findings of Inspection Report No.
50-245/88-200,- conducted June, 1988.
Inspection of the licensee actions in
response to NRC Bulletin No. 88-07 and Supplement 1 pertaining to reactor power
oscillations was also conducted.
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Inspection Results: The inspection identified several unresolved items concern-
.ing the E0Ps (see sections 3 and 4). The items are:
1)
The licensee's technical justification for the licensee's deviation from
the BWR Owner's Group Emergency Procedure Guideline, Revision 4 (accepted
by NRC staff safety evaluation report) were incomplete.
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2)
Inconsistent application of administrative controls to the 590 series
supplemental procedures related to E0P implementation.
3)
Weak validation and verification program for E0P revisions.
4)
A lack of E0P entry conditions for some monitored and unmonitored radia-
tion release points.
5)
A lack of operator training regarding determination of RPV water level-
during degraded primary containment conditions.
6)
Weak implementation of Human Factor principles.
Overall, the inspection findings of this report as detailed in sections 3 and 4
indicate a weakness in the programmatic approach the licensee has taken to
implement Revision 4 of the Emergency Procedure Guidelines. NRC administered
requalification examinations were conducted concurrently with the inspection.
1he results of the requalification examination indicate operators are able to
use the E0Ps, even though the inspection results indicate weaknesses in the
E0Ps.
The inspector determined that licensee actions in response to NRC Bulletin 88-07 and Supplement I were adequately implemented at Millstone Unit 1.
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DETAILS
1.0 Introduction and Overview
1.1 Background
The NRC's Office of Nuclear Reactor Regulation (NRR) conducted a special
safety team inspection on June 13 through 30, 1988 of the Millstone Unit 1
Emergency Operating Procedures (EOPs).
The inspection results are contained
in Inspection Report No. 50-245/88-200.
The results of that inspection
were:
1)
The revised verification and validation procedures were not utilized
to perform a complete review of the E0Ps and the operating procedures
referenced by the E0Ps were never verified or validated.
2)
The maintenance of the E0Ps and the Plant Specific Technical Guide-
lines (PSTG) as design basis documents was not adequate.
3)
The basis of the Primary Containment Control Guidelines of the E0Ps
was deficient.
4)
The human factors engineering of the E0Ps was deficient.
5)
The procedural adequacy of the E0Ps was deficient.
6)
Several deficiencies were noted during the E0P simulator
exercises.
The licensee's response to the inspection report is contained in letters
dated July 29,1%8, and October 28, 1988.
In lett2rs dated February 29,
1989, and July 25, 1989, the licensee submitted information concerning
selected deviations that were planned to be taken from the Emergency
Procedure Guidelines (EPG) prepared by the General Electric Boiling Water
Reactors Owners Group (BWJG) on this topic. The licensee subsequently
revised their E0Ps using General Electric Topical Report'NE00-31331
" Emergency Procedure Guidelines" (EPG) Revision 4 and implemented the
revised E0Ps September 1, 1989.
1.2 Purpose
An announced inspection of the Emergency Operating Procedures was
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conducted at Millstone Unit I during the week of October 23 - 27, 1989.
The purpose of the inspection was to review selected deviations the
licensee had taken from the General Electric Topical Report NEDO-31331
" Emergency Procedure Guidelines" and determine that Human Factor princi-
pies were utilized in the implementation of the guidelines. The inspec-
tion team in the E0P area consisted of a region based inspector and two
Headquarters based human factors specialists.
,
Also, the licensee's implementation of NRC Bulletin No. 88-07 and Supplement
1 pertaining to power oscillation were also inspected.
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1.3 Methodology
The invector reviewed the licensee's deviations from the General Electric
Topical Report NED0-31331 " Emergency Procedure Guidelines" Revision 4 and
the related NRC Safety Evaluation Report (SER) dated September 12, 1988.
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The deviations are discussed in the licensee's Plant Specific Technical
Guidelines-(PSTG) 1-0PS-3.07, dated October 19, 1989.
In addition, the
inspector reviewed the following procedures:
Ero 570 - RPV Control, consisting of the following procedures:
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Level Control, RPV Flooding, Primary Containment Flooding,
Dressure Control, Depressurization, and Steam Cooling.
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E0P 575 - Failure to Scram, consisting of the following procedures:
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Level Control, RPV FlemMng, Primary Containment Flooding,
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Pressure Control, Depressurization, and Power. Control.
E0P 580 - Primary Containment Control, consisting of the following
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procedures:
3
Torus water level, Drywell Temperature, Primary Containment
Pressure, Torus Water Temperature, and Primary Containment
. Hydrogen,
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E0P 585 - Secondary Cor.tainment Control, consisting of the following
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procedures:
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Temperature, Radiation, Water Level, and Radioactiv!ty Release
590 Series (EOP supplemental) procedures as listed in section 3.3
The Human' Factors inspection consisted of a desktop review of the E0Ps and
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Writers Guide using criteria established in Temporary Instruction 2515/92
Rev. 1, Supplement I to 0737. " Requirement for Emergency Response Capabil-
ity;" NUREG - 0899, " Guidelines for the Development of Emergency Operat-
ing1 Procedures;" and NUREG - 1338, " Lessons Learned From the Special
Inspection Program for Emergency Operating Procedures." The E0P Supple-
mental Procedures (590's) were also included in the review.
In addition,
the following administrative procedures were reviewed:
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OP-261-
Control of Operator Aids
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Unit 1 Verification Program
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Unit 1 Validation Program
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E0P Administration
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Verification and Validation Program for
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E0P Supplemental Procedures
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E0P 568
Unit One Emergency Operating Procedures
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and Off Normal Procedures User's Guide
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OTBI-6
Operating Training Branch Instruction:
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Operating. Plant Procedure Changes
ACP-QA-3.02A- Writers Guide for Millstone Procedures
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' Millstone Unit 1 personnel involved in the E0P program were interviewed to
clarify and augment the information gained from reviewing documents.
In addi-
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tion, walkdowns in the control room of five supplemental procedures were
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conducted.
1.4- Persons Contacted
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Millstone Nuclear Energy Company
- S. Scace, Millstone Station Superintendent
- J. Stetz, Millstone Unit-1 Superintendent
- P. Blastoli Supervisor-Nuclear Licensing
- P.~ Miner, Licensing Engineer
. R, Palmieri, Operations Supervisor
- N. Jain, Reactor Engineer
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- R. Kraemer, Shift Supervisor
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U. S. Nuclear Regulatory Commission
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- J. Stolz, NRR
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- C, Sisco, Operations Engineer, Region I
- B. Raymond, Senior Resident Inspector
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- *G. Galletti, NRR
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- A. Sutthoff, NRR
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- M. Boyle, NRR
- Denotes personnel present at exit meeting
' 2.0 Summary of Findings
The inspection identified several unresolved items concerning the Emerg-
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ency Operating Procedurn (EOPs).
1). The licensee's- technical justification for-the licensee's deviation
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from the BWR Owner's Group Emergency Procedure Guidelines (EPG),
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Revision 4 (accepted by NRC staff safety evaluation report) were
.incorrplete (Unresolved Item 245/89-19-01, paragraph 3.1).
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2)
There was an inconsistent application (,? administrative controls of
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the 590- series supplemental procedures related to E0P implementation
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(Unresolved Iten. 245/89-19-02, paragraph 3.2).
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3)
' Weak * validation and verification program for E0P revisions
(Unresolved Item 245/89-19-03, Paragraph 3.3).
4)
A lack of E0P entry conditions for some monitored and unmonitored
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. radiation release points (Unresolved Item- 245/89-19-04, Paragraph
,
3.3).
)
5)
A lack of operator training regarding determination of RPV water
level ~during degraded primary containment conditions (Unresolved Item
3
-245/89-19-05, Paragraph 3.3).
6)
Weak implementation of Human Factor principles (Unresolved Item 245/
89-19-06, Section 4).
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.The inspection findings of this report in areas 2, 3, and 6 above are similar
in nature to those findings identified in Inspection No. 50-245/88-200_(see
paragraph 1.1).
The inspector determined that the licensee's actions in response to NRC Bulle-
tin 88-07 and Supplemert I were adequately implemented at Millstone Unit 1,
3.0 ' Emergency Operating Procedure Review
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3.1-
Emergency Procedure Guideline (EpG)/ Plant Specific Technical Guideline
(PSTG) Comparison
The inspector reviewed the licensee's justification for the deviations
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from the General Electric Topical Report NE00-31331, " Emergency Procedure
Guidelines", (EPG) (accepted by NRC staff safety evaluation report),
Revision 4 (EPG). The licensee's justifications for the deviations are
contained in 1-0PS-3.07 (PSTG) dated October 19, 1989, and letters dated-
,
July 25, October 19 and December 27, 1989. As a result of the review of
the' licensee identified deviations ~from the EPGs, the NRC staff identified
that the licensee's technical deviation justifications are incomplete.
The major deviations are:
.
1)'
If there is no injection system operating and the Isolation Condenser
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(IC) it ot available, emergency RPV depressurizaticn is not initi-
ated untii RPV level reaches 2/3 core height (re: E0P_570 Page 49).
The EPGs specify initiation of emergency RPV depressurization when
RPV level reaches the top of the active fuel (TAF).
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2)
If one core spray pump is operating, primary containment flooding is
performed only when RPV. level reaches is core height (re: E0P 570-Page
30-31)-
The EPGs specify primary containment flooding when RPV level
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reaches TAF.
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If there is no injection . system available, an emergency depressuri-
zation to protect primary or secondary containment will not be
performed when a primary or secondary containment parameter exceeds
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setlimits(re: E0P 570 Page 42-43).
The EPGs specify emergency RPV.
depressurization irrespective of injection system availability when a
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primary containment parameter exceeds set limits.
. These'particular deviations reflect strategies which deviate from that
previously accepted by NRC staff in their SER of September 12, 1988. When
a decision between a possible loss of adequate core cooling and a loss of
primary containment integrity must be made, the NRC staff's SER in. the
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Emergency Procedure Guidelines, Revision 4, specifies to preferentially
choose to maintain primary. containment integrity in order to protect
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against the uncontrolled release of radioactivity to the general public
from a degraded core condition. As noted above, the M111 store Unit 1 E0P
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strategy does not preferentially choose' to maintain primary containment
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integrity before adequate core cooling.
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Further, the NRC staff SER on the EPGs specify that primary containment
flooding be initiated if reactor level cannot be maintained above TAF
because adequate core cooling cannot be guaranteed.
The Millstone Unit 1
initiation of primary containment flooding is similarly defined when
adequate core cooling cannot be maintained. However, M111 stone's defini-
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tion of. adequate core cooling has an optional definition in addition to
the above TAF specification namely,. above one-half core height with a core
spray pump operating.
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The technical justifications for the licensee's deviations from the EPG
were incomplete. In a telephone conference call on October 25, 1989, with.
the licensee, .the NRC staff determined that additional regulatory review
is warranted.
The NRC staff review of the licensee's justification of
EPG/PSTG differences is an unresolved-item (245/89-19-01).
3.2 E0P Administration
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The inspector determined that OP-264 E0P Administration requires-that all
E0P changes.be Plant Operation Review Committee (p0RC)~ approved prior to
. implementation. . The 590 series procedures (supplemental procedures)
contain procedure steps to implement necessary emergency actions of the
E0Ps. The supplemental ~ orocedures are administrative 1y controlled as
operating. procedures and do not require PORC approval of changes prior to
implementation.
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The licensee agreed to review'the inspector's- finding in this area and
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modify the administrative program control of the supplemental procedures.
The inconsistent application of administrative controls to the 590 series
(supplemental procedures) is an unresolved item (245/89-19-02).
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-3.3_.Procedura1 Deficiencies
The. inspector identified several deficiencies with respect to the E0Ps.
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The deficiencies deal with a procedure referencing error and poor plant
labeling -
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_EOP 575 (Pg. 49) Step FS0-5.1 references ATWS Logic Trip Bypassing as
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590.21. The correct procedure reference is 590.22
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590.19." Bypassing all Group I Isolation Signals Except HIGH-HIGH
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Steam Line Radiation"- The relays and terminals required to be
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. Jumpered are not clearly identified within the control room panel CRP
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915.
590.21 " Defeating RPS Logic Trips"- The fuse numbers as identified
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in the procedure must be converted to the appropriate terminal. strip
and fuse number using an unapproved operator aid located inside
control room panels CRP 915 and CRP 917.
590.22 " Defeating ATWS Logic Trips"- The procedure requires the four
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inverter power' supply breakers to be opened. Two of the breakers-
have positions indicated as-open and close, two breakers on and off.
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590.23 " Containment Vent Procedure"- The procedure _contains equipment'
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nomenclature that differs from the nomenclature of the control room
boards.
These deficiencies were similar in nature to those identified in Inspec-
tion' Report No. 50-245/88-200 and appeared to be the result of a weak
validation and verification of the E0P revisions.
The licensee agreed to
review and modify the plant labeling'as required to address the above
findings. The resolution of these deficiencies is an unresolved item
(245/89-19-03).
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Further, the inspector identified an area of weakness of the E0Ps in that
some entry conditions from monitored and possibly unmonitored radiation-
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release points are absent from the E0Ps.
Specifically, an Isolation
Condenser tube leak and possible radiation release is not an entry condi-
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tion into the E0Ps from a monitored release point. .The release point is
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listed on Table H-1, On Site Assessment Equipment in the. Millstone Unit 1
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The release point is monitored by ARM Station 35, Isola-
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tion Condenser Vent Line.
Verbal reports from outside the control room-
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announcing a radiation release beyond the secondary containment are not an
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entry condition into the E0Ps from a possible unmonitored release pathway.
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The EPG (as accepted by NRC staff SER) _ specifies an E0P entry condition
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being offsite release rate above the offsite release rate which requires
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The licensee agreed to review and modify the E0Ps as necessary to address
this finding. The lack of entry conditions into the E0Ps is-an unresolved
item (245/89-19-04).
Also, the inspector identified that the E0Ps do not specifically direct
the operators to make a determination that reactor water level is unknown
when drywell bulk temperature and reactor pressure exceed the graphs in
accordance with' Caution #1 of the EPGs or the licensees deviation document.
However, at Millstone Unit 1, the operators are instructed that there is a
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time period for the RPV water level instrument reference legs to reach
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saturation conditions and this may be considered in their determination of
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reactor water level indication thereby delaying reactor vessel flooding.
(re: E0P) 570 Page 8, Figure 4.
The time period is not-specifically
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addressed in the EPG or the PSTG, At this point, the EPGs spe:ify that
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reactor vessel flooding is to be accomplished.
The concern is that the
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facility training incorrectly interprets the EPG for this area.
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The licensee' agreed to. review and modify the operators training programs
as necessary to address this finding.
This weakness in operator training.
is an unresolved item (245/89-19-05).
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4.0 Human Factors' Review of the Emergency Operating Procedures
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4.1 Introduction
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.A number of concerns related to the continuing control of Millstone Unit 1
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E0Ps were' identified.
Some of these issues reflect concerns previously
identified in Inspection Report No. 50-245/88-200, and the SER for the
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Millstone Unit 1 Procedures Generation Package, dated September 24, 1984.
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These areas of concern are addressed below.
- 4.2 Writers Guide
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In order to prepare clear, consistent E0Ps that will support operator
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performance and-minimize errors, a complete and restrictive writers guide
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-is'necessary. Writers guides that are incomplete and nonrestrictive leave
format decisions to the writer's judgement and preference. Because indi-
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vidual writer's judgements vary, this will result in increasingly in-
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' consistent and complex procedures over time.
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The Millstone Unit 1 E0P writers guide lecks direction on a number of
aspects of the E0Ps.
For example:
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Transitions between procedures are not addressed.
This issue was
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previously identified by both the 1984 SER and the 1988 Inspection-
Report'.
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The format for the "when, then" logic step and symbol are not
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addrused in the writer's guide.
LTheuseofasemi-colonisnotaddressedinthewritersguide,
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. although this form of punctuation is commonly used in the E0Ps.
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The guidance provided in the writers guide on the following items is not
sufficient to ensure consistent structure:
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Typestyle and typesize are not defined. They are merely described
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as " simple, easy to read."
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The format for figures, tables, and graphs is not described, and.
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examples are not provided. This issue was previously identified by
both the 1984 SER and 1988 Inspection Report.
Highlighting and emphasis methods are not adequately described. The
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guidance. indicates that these methods are to be used "where appro-
priate." This issue was previously identified by the 1988 Inspection
Report.
The format for entry conditions is not defined.
The only guidance
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is that entry conditions are to be formatted consistently, but no
example or guidance is-included.
This issue was previously;identi-
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fied in the 1988 Inspection Report.
The E0P writers guide reflects a lack of application of human factors
principles.
For example:
The format principles.used for E0Ps differ from that applied to E0P-
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Supplemental Procedures (590 series),-although these procedures are
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.used.in= conjunction with E0Ps.
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4.3 . Verification and Validation'
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AL thorough verification and validation of EOPs ensures that the technical
and format bases documents (PSTG and writers-guide) have been applied; to
ensure that.the procedures-. correspond to plant nomenclature and equipment;
and to ensure that the procedures are usable and can be performed.
Several concerns were identified with the verification and validation
' procedures for E0Ps and 09? Supplemental Procedures.(590s), and with the
implementation of these procedures. The concerns are'as follows:
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The checklists included in the E0P~ and the supplemental procedures
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verification and validation procedures contain a number.of subjective
criteria.
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The Verification and validation procedure for E0P Supplemental Proce-
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dures does not require complete validation of the procedures.
It
indicates that as much of the procedure " as practical" should be
validated.
The verification and validation procedures for E0P Supplemental
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Procedures does not define the required methods of validation.
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-4.4 ~ Ongoing Maintenance and Revision Of Procedures
After the use of adequate bases documents is checked through verification
and validation, continuing integrity of the procedures is assured through
a complete maintenance and revision program.
The following concerns were
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identified with the E0P program in this area:
No method exists for ensuring that changes to procedures referenced
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by E0Psaor E0P supplemental procedures are reflected in the E0Ps and
E0P supplemental procedures.
'No method exists to ensure that changes ~ to operator aids are reflected
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in the.EOPs or E0P supplemental procedures.
Operator aids that are necessary for execution of E0P Supplemental.
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Procedures are not the responsibility of the E0P program staff; and,
therefore, the information in those aids is not subject to the same
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presentation and control as the E0Ps or E0P Supplemental Procedures.
The licensee agreed to review the human factors concerns resulting from
the inspection.
The human factor concerns addressed in sections 4.2 to
4.4-are collectively considered an unresolved item (245/89-19-06).
5;0 E0P Summary
The inspection findings of~this report as detailed in sections 3 and 4
indicate a weakness in the-programmatic approach the licensee has taken to
implement Revision 4 of the Emergency Procedure Guidelines. The technical
deviations from the BWROG EPG appear to be incompletely evaluated in the
licensee's deviation document to justify differences between the EPG and
PSTG document. . Further, some of the deficiencies noted in this inspection,
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?especially in the area of human factors appear to be repetitive of previous
inspection findings in the E0P area.
NRC administered requalification
examinations were conducted concurrently with the inspection. The results
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of the requalification examination indicate that operators are able to
)(,
. effectively use the E0Ps even though the inspection results indicate
weaknesses in the licensee's E0P program,
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6.0 Inspectiori of' Implementation of 'NRC Bulletin 88-07 and Supplement 1,
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BWR Power Oscillations (NRC Temporary Irstruction 2515/99)
' An inspection was conducted to' evaluate the licensee's implementation of
NRC Bulletin (NRCB) 88-07 and Supplement 1 to this bulletin. The.11cen-
see's responses to NRCB 88-07 and supplement 1 are contained in letters
A07301 dated September 14, 1988; B13076 dated November 14, 1988; and
A07742 dated February 28, 1989.
6.1 Training.
The inspector reviewed lesson plans for operator training and determined
that the training material properly addressed the power oscillation issue
as requested by NRCB 88-07 and Supplement 1.
Training was conducted for
all licensed operators, including shift technical advisors, in a timely
fashion.
Individual operator interviews were not conducted as the NRC requalifica-
tion examinations were conducted concurrently with the inspection. The
results.of the NRC administered requalification examination indicated that
this training was effective.
6.2 Procedural Implementation
The' inspector reviewed the documentation of the procedural assessment
conducted by the licensee to incorporate NRCB 88-07 and Supplement 1.
.
-The inspector determined that the assessment was adequate. The inspector
r' viewed the below listed-procedures and determined adequate procedural
e
instruction is provided to prevent, detect, and suppress power oscilla-
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tions.
0NP-526' Uncontrolled Power Oscillations
. Power Operation Procedure
OP-301-
Nuclear Steam Supply System, Section 5.7, Removing
Recirculation Pump From Service
Approach to Criticality
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6.3 Installed Instrumentation / Equipment
The inspector reviewed the assessment of the installed instrumentation
used to detect power oscillations.
From this review, the inspector deter-
mined that installed instrumentation is adequate to detect power oscilla-
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The licensee's. initiative:to assess the performance of recirculation pump
minimum speed characteristics was thorough. The assessment resulted in a
change of the minimum speed from 28% to 32% which effectively resulted in
eliminating plant operations in the restricted area of the Power / Flow Map
-during dual pump minimum speed operations.
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6.4 Summary
The inspector determined that the plant operators are adequately trained
to prevent, detect, and suppress power. oscillations. The plant procedures
provide adequate direction to the operating staff, and the plant is
equipped with adequate instrumentation to provide indication of power
oscillations.
7.0 Unresolved Item
Unresolved items are matters about which more information is required in
order to ascertain whether they are acceptable items, violations or devia-
tions. Unresolved items addressed in this report are in sections 3 and 4.
8' 0 Management Mcetings
.
An entrance meeting was conducted at the Training Center on October 23,
1989. A conference call between the licensee and NRC management was con-
ducted on October 25, 1989, to discuss the EPG and PSTG deviations. An
exit meeting was conducted on October 27, 1989.
Those in attendonce at
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the exit meeting are marked by asterisk (*) in paragraph 1.4 of this
report.
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